D. BankInformation.pdf

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This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory/Brookhaven Science Associates (BNL/BSA), which operates under contract with the U.S. Department of Energy. The form collects essential banking information from vendors to enable electronic payments through the Automated Clearing House (ACH) system.

The form requires vendors to provide their company name/DBA, vendor number (if applicable), Tax ID Number (TIN), and banking details including financial institution name, routing/ABA number, and checking account number. The authorization section establishes the vendor's consent for BNL/BSA to initiate ACH credit entries and corrections to the specified account, remaining in effect until written termination notice is received. The form requires signature from an authorized representative, along with their email and phone contact information.

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Managed by Brookhaven Science Associates, LLC under contract with the

U.S. Department of Energy

Vendor ACH Authorization Form

VENDOR INFORMATION

Vendor/Company Name or DBA:

Vendor Number (if Applicable):

Tax ID Number (TIN):

DEPOSITORY INFORMATION

Financial Institution:

Routing/Transit/ABA Number:

Checking Account Number:

AUTHORIZATION

I (we) hereby authorize Brookhaven National Laboratory/Brookhaven Science Associates to make payments by initiating ACH (Automated Clearing House) credit entries or correcting entries to the account indicated above and associated with the financial institution named above. This authorization will remain in effect until BNL/BSA receives written notification to terminate or modify the same. It is my (our) understanding that credit authorizations may be revoked only by notification of the originator as described by NACHA (National Automated Clearing House Association) law.

Authorized Representative:

Email:

Phone:

Signature: Date:

VendorCompany Name or DBA:
Vendor Number if Applicable:
Tax ID Number TIN:
Financial Institution:
RoutingTransitABA Number:
Checking Account Number:
Authorized Representative:
Email:
Phone:
Date:

File details come from the government source that posted it. Updated .